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HomeMy WebLinkAboutApp-License-Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $185.00 Food Establishment License Number: BOHF-14-0344-08 Issue Date: 1/1/2022 Mailing Address: Location Address: KRISTINA'S KITCHEN INC. 134 ROUTE 6A OPTIMIST CAFE YARMOUTH PORT. MA 02675 134 ROUTE 6A YARMOUTHPORT, MA 02675 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Food Service; Common Victualler This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 unless sooner suspended or revoked and is not transferable. Conditions SEATING: 80 Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston e Bruce Murphy, PH, '.S., CHO Health Director TOWN OF YARMOUTH BOARD OF HEALTH fe APPLICATION FOR LICENSE/PERMIT -2022 __ * Please complete form and attach all necessary documents by December 18, 2021. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: 1p ti nqin 1` Cal. -- TAX ID: 3g-32')Z179 LOCATION ADDRESS: I3L )24-6A- /ttj y)enAth p8-o- (fl3 n9iDs TEL.#: 508 3ba /Day MAILING ADDRESS: E-MAIL ADDRESS: iL tAAphi 4ga VO.c. v� �r OWNER NAME: (n S h vi u 7)`-i d- )&A b c ,(— CORPORATION NAME (IF APPLICABLE): kr7 sitykoLS t+-Cir�WL '1e--- MANAGER'S NAME: , SS LQ., Mc (Y1Ct-h0 ,1TEL.#: -3 /-i '77 MAILING ADDRESS: 56t..rilfL POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. Pool operators must list a minimum of two e s' : s yees L..gently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CPR • . mg one certified employee on premises at all times. Please list the employees below and attach col'-: . their certifications to this form. The Health Department will not use past years' records. You m $ ovide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past yea L) You must provide new copies and maintain a file at your establishment. c2SS1 e- rYlc.Pona-h(rc`► NOV8 2 2� 1. 2. HEALTH DEPT. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. 1. 5 SS LC ,c IrYkkt)6—P 2. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. i. �SS Le ‘(Y)c 2. IXritcytik1 )t t'.'"l)"LQ,t -- HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must rovide new copies and maintain a file at your place of business. 1. ✓`1�� -l�Pl� -D-t---61k-9--1- 2. 3. 4. RESTAURANT SEATING: TOTAL # 80 Under Chapter 152, Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED 1,/ Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO NOV 1 8 2091 MOTELS AND OTHER LODGING ESTABLISHMENTS HEALTH DEPT. TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(90)days within any six (6) month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended,shall generally be considered Transient. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three (3) days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, and submitted to the Health Department three(3)days prior to opening,and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three(3)days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department, or from the Town's website at www.yarmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFÉS: Outside cafes(i.e., outdoor seating with waiter/waitress service), must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her permit within thirty (30) days of the previous year's permit expiration date is considered an expired license, and the tobacco license cap is reduced. The Commonwealth of Massachusetts Print Form *;_ Department of Industrial Accidents E_, —ti. Office of Investigations k = _4 1 Congress Street, Suite 100 I.7-11—=', Boston, MA 02114-2017 ,r , www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information (� Please Print Legibly Business/Organization Name: cpV1kL .. _ �T� __________ Address: i.?)`l 12--+ (0A- City/State/Zip: YCirrynk,*\_ C (1--- VA / Phone #: A33 g (o - /ba / Are you an employer? Check the appropriate box: Business Type(required): 1) I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. Zestaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7_ ❑ Office and/or Sales(incl. real estate, auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment I E.` OWED their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care I A 1 $ 2021 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other HEALTH DEPT. *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compe sation insur nce for my employees. Below is the policy information. Insurance Company Name: —ThQ bus 4/624. C ./ Insurer's Address: &°D W i e-ilirta B 1v City/State/Zip: , t / � 7 S /0 7C 7825 Iii � Expiration Date: a �Z Policy#or Self-ins. Lic.#0CgWee .1_-&&15.."- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce ' under the pains and penalties of perjury that the information provided above is true and correct Signature: /(1/ , •J//,f Date: /f/-1 — 102/ Phone#: eta) (o7 o-- 9 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License it Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia °E6.)grlii. | | , / § w ki c \ § $ \ 2 e a Z 0 o - \ 2 > .... } @ � / �_ ƒ a E * -I ) 2 u / § 0 \ � b � \ , ` A0 —0 V) r- \ �co X _ �CN � IL de CV p I 0111) o | � o } him 0 2 / _2 \ } ± ›. \ f a al Imotilm 0 - $ ƒ - / 4 J 7 .q 0 = 2 talli ‘116) 411 + ) } 13- 4- 0 o / | oc Z3 / \ \ E J-- \ \ t INIIIIIIII 2>11 Lialli � 2 �\ . 4 \ Ill. IMMIIII Z -2 \/ \ f2 _0 Cie t 7 / ><6 x < © �. ,\ \ } 7 ° ? ¥ $ \ 5 \ ) iii 1.1.1 < a) „., o ¥ / o \\ 2 � ¥ / co 1-= z� . �\ til kJ D / \ <7 - \ \ \ \ ƒ � U & 0 \\ \ \ \ \ - N. - .. -., \ rill 2® j ; « ; t « m ! 4 =/ fl,H y:y . . «In: - 4 i \, \ \ . \ \ �\ - \\ / a! 3 !a = § } $a § } � \ � � � } i \\ y . . . 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W m CINI, ,44 " tz:::, r e1L17- I 4Z• lri 1‘ 1 picker Road _ X f_ n — Phone: (508) 347-8181 P.O.Box 38 R•E•S•O•U •R•C•E.S Fax: (508) 347-3149 Sturbridge, MA 01566 , < h www.rehabresourcesinc.org GLC LIJLD JAN 3 ?Oi HEAL i-, J 1 JJ . January 28, 2013 Board of Health Yarmouth, MA To Whom It May Concern, This is to confirm that Kristina Dittmer and Daryl Dittmer have been trained in the Conscious Choking Technique/ Heimlich Maneuver on January 7, 2013. I can be reached at 508-347-8181 Ext. 103 for further assistance. Sincerely yours, Jane Cutting .JCI V.Jr OIL ..i.'+t:4c1.tC11 CPR/First Aid Instructor Providing quality support services for people with disabilities and health care services to the community November 13, 2021 To Whom It May Concern: Please contact Jessie McMahon, General Manager- Optimist Café, to schedule all inspections. We are currently only open on an as needed basis. Her phone number is #508-364-1487. Thank you. Kristina Dittmer, Owner- Optimist Café Cell #860-670-5896 NOV 1 8 2021 HEALTH DEPT. To: Town of Yarmouth From: Kristina Dittmer, Owner- Optimist Café Date: November 15, 2021 Re: Winter Break This is to inform you that we will be closed for a short winter break on or around December 19, 2021 until approximately March 15, 2022. Please contact me if there are any questions. Kristina Dittmer ELICaPilLiD NOV 18 2021 HEALTH DEPT.